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The client with chronic stable angina is prescribed a beta blocker. The nurse is reinforcing instructions. What instruction should the nurse include?
- A. Take the medication with a meal.
- B. Report a pulse rate below 60 beats per minute.
- C. Discontinue the medication if dizziness occurs.
- D. Avoid drinking grapefruit juice.
Correct Answer: B
Rationale: The correct instruction for the nurse to include is to advise the client to report a pulse rate below 60 beats per minute. Beta blockers are known to lower heart rate, and a pulse rate below 60 beats per minute may indicate bradycardia, a condition that requires medical attention. Option A, 'Take the medication with a meal,' is incorrect because beta blockers don't necessarily need to be taken with food. Option C, 'Discontinue the medication if dizziness occurs,' is incorrect because abrupt cessation of beta blockers can lead to rebound hypertension and other adverse effects. Option D, 'Avoid drinking grapefruit juice,' is unrelated to beta blockers' mechanism of action or side effects.
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Which laboratory test should be monitored to evaluate the effectiveness of anticoagulant therapy in a client with deep vein thrombosis (DVT)?
- A. Complete blood count (CBC)
- B. Activated partial thromboplastin time (aPTT)
- C. Serum electrolytes
- D. Liver function tests
Correct Answer: B
Rationale: Activated partial thromboplastin time (aPTT) is the laboratory test monitored to evaluate the effectiveness of anticoagulant therapy, particularly with heparin. It measures the time it takes for blood to clot, and monitoring aPTT helps ensure the therapeutic range is maintained to prevent clot formation and excessive bleeding. Choices A, C, and D are incorrect because a complete blood count (CBC) assesses overall health, serum electrolytes evaluate the body's electrolyte balance, and liver function tests assess liver health, none of which directly evaluate the effectiveness of anticoagulant therapy for DVT.
The LPN/LVN is assisting with the care of a client who has been diagnosed with a myocardial infarction (MI). Which laboratory test result would the nurse expect to see elevated within the first 24 hours of the client's admission?
- A. Serum troponin
- B. Serum creatinine
- C. Serum sodium
- D. Serum albumin
Correct Answer: A
Rationale: Elevated serum troponin levels are indicative of myocardial damage and are commonly used as a diagnostic marker for myocardial infarction. Troponin levels typically rise within a few hours of an MI and remain elevated for several days, making it a crucial test for early detection and monitoring of cardiac injury. Serum creatinine is not typically elevated in the acute phase of a myocardial infarction. Serum sodium and serum albumin levels are not directly associated with myocardial infarction and are unlikely to be elevated in the first 24 hours following an MI.
The nurse is assisting with the care of a client who is on a continuous heparin infusion for deep vein thrombosis (DVT). Which laboratory test should the nurse monitor to evaluate the effectiveness of the therapy?
- A. Prothrombin time (PT)
- B. Activated partial thromboplastin time (aPTT)
- C. International normalized ratio (INR)
- D. Platelet count
Correct Answer: B
Rationale: To evaluate the effectiveness of heparin therapy in a client with DVT, the nurse should monitor the activated partial thromboplastin time (aPTT). The aPTT test helps ensure that the dose of heparin is within the therapeutic range, which is essential for preventing clot formation or excessive bleeding. Monitoring aPTT is crucial in managing patients on heparin therapy to maintain the delicate balance between preventing thrombosis and avoiding hemorrhage. Prothrombin time (PT) and International normalized ratio (INR) are more indicative of warfarin therapy effectiveness, not heparin. Platelet count assesses platelet levels and function, not the effectiveness of heparin therapy for DVT.
The nurse is caring for a client who has returned to the unit after undergoing a cardiac catheterization. The nurse should monitor for which common complication following this procedure?
- A. Hypertension
- B. Hypotension
- C. Hemorrhage
- D. Hyperglycemia
Correct Answer: C
Rationale: Following a cardiac catheterization, a common complication to monitor for is bleeding or hemorrhage at the catheter insertion site. Hemorrhage is a significant concern due to the potential for rapid blood loss, leading to hypovolemic shock and other serious complications. Monitoring for signs of bleeding, such as swelling, hematoma, or drop in hemoglobin levels, is crucial for timely intervention. Hypertension is not a common complication post-cardiac catheterization; instead, hypotension may occur due to vasovagal response or bleeding. Hyperglycemia is not typically associated with cardiac catheterization unless the client has pre-existing diabetes or stress-induced hyperglycemia.
The client is starting therapy with digoxin (Lanoxin). What instruction should the nurse reinforce about the medication?
- A. Take the medication with meals.
- B. Avoid dairy products.
- C. Monitor for yellow or blurred vision.
- D. Increase potassium-rich foods in the diet.
Correct Answer: C
Rationale: The correct answer is C: 'Monitor for yellow or blurred vision.' When a client is taking digoxin, it is crucial to monitor for signs of toxicity, such as yellow or blurred vision, as these can indicate an adverse reaction. Reporting these visual disturbances promptly to the healthcare provider is important for further evaluation and management to prevent potential complications. Choices A, B, and D are incorrect because taking digoxin with meals, avoiding dairy products, or increasing potassium-rich foods are not specific instructions related to monitoring for adverse effects of digoxin therapy.